The Essentiality of the Family Doctor
for the Haitian Healthcare System
André Vulcain, MD
Every time we attempt a serious discussion on the realities of the Haitian healthcare system, we need to start with these inescapable premises: the extreme vulnerabilities of the Haitian people, the deplorable health status of the communities and the profound discrepancies between the challenges posed by the health problems and the responses of the healthcare system.
Besides a partial success in the reduction of infant mortality during the past 25 years and a real effort to curb the expansion of the HIV/AIDS epidemic and tuberculosis during the last 2 decades, the healthcare system globally seems to be caught in its own time warp, straddled between the end of the XIXth century and the first half of the XXst century, oblivious of the advances in the various fields of medical care in general and primary care . Essential functions of modern medical and public health practices, such as networking and coordination, team-based care, continuous quality improvement, safety of medical care, information and medical technology, doctor/patient relationship, control of highly prevalent diseases, preparedness and surge capacity for epidemiological and natural disasters , are in a precarious state throughout the system .This situation is hampering the effectiveness of all health initiatives in this country. Another important point is that the system has lost its credibility in the eyes of the Haitian population, which has become cynical about the Haitian health care system and has expressed daily, in various ways, a vote of no confidence in this system.
Compounding this are the lack of resources of all kinds and more importantly, the inappropriate use of available resources.
Getting out of this predicament will require political will, development of financial schemes to support a more equitable healthcare system, redirection of available resources to strengthen the healthcare infrastructure and addressing the human resources issues.
In fact, doting Haiti with an effective health care system requires at this juncture to make judicious choices in selecting health care personnel to be placed in strategic locations in the healthcare delivery system. It will require prioritizing the personnel that can give you the best return on the investment of scarce resources. Importantly, the prioritized personnel need to function as dynamic and capable agents of change to turn the tide and to champion much- needed new paradigms in a system captured by inertia and a retrograde march.
The problem of the adequacy of human resources vis- a -vis the needs of the Haitian health system is urgent to address. The Ministry of Health of Haiti has issued in 2016 a white paper titled “Le Paquet Esssentiel de Services”. This document serves as a practical reference for the essential health services to be offered to everyone and delineates the personnel required to deliver the package of care. Among other health professionals, the family physician is listed as a critical resource to put this directive into effect. In 1994,a landmark international conference titled “The Contribution of the Family Doctor”, under the joint auspices of the World Health Organization and the WONCA(World Organization of Family Doctors) held in Ontario, Canada, has recommended the following: “To meet people’s needs fundamental changes must occur in the health care system, in the medical profession, and in the medical schools and other educational institutions. The family doctor should have a central role in the achievement of quality, cost -effectiveness and equity in health care systems. To fulfill this responsibility, the medical doctor must be highly competent in- patient care and must integrate individual and community health care”
Since this declaration, the transformational value of family medicine has been recognized in many countries in the world. This recommendation was reiterated at different times in various health reports of the WHO Assembly. As Haiti was conceptually moving toward a system with the goal of a strong primary care system, the Haiti Project was established at the University of Miami to promote family medicine in Haiti and contribute in the improvement of health services to the Haitian communities.
In 1999, a Family Medicine Residency Program and a Family Practice Center were established at Hopital Justinien, Cap Haitien in the framework of a collaborative partnership between the Ministry of Health of Haiti and the University of Miami Miller School of Medicine .The program has trained up to 70 family doctors through a rigorous 3-year curriculum and over 1000 medical students have been familiarized with the biopsychosocial model of care through a-month rotation at the Family Practice Center. There were 230000 patient/visits at this center for a wide variety of clinical situations. Patients of all- age groups have received highly individualized, continuous, comprehensive and compassionate medical care provided by the residents and attendings of the service. Women’s health interventions, HIV care and management of mental health issues are part of the wide palette of services offered at the family practice center of Hôpital Justinien. Health education and implementation of age-appropriate preventive interventions have an important role in the clinical encounters. Beyond the broad clinical competence, the family medicine residency programs strive to include additional attributes for the Haitian family physician to play a leadership role in the transformation of the Haitian health care system.
This program represents one of the most consequential health initiatives in the country during the past 20 years as it has been making a positive mark in the system. Another family medicine program has been established in Saint Marc Hospital, modeled on the Justinien Hospital program. The medical schools of the country are working to make family medicine an essential part of the training of the medical students and to train more family doctors. Plans are been considered to develop family practice centers in the mid-level hospitals and major community health centers where the Haitian family physicians will eventually be stationed.
The expectation is that staffing these health centers with a mix of well-trained family physicians and other specialists will allow them to be more cost-effective and more supportive of the primary care network and will optimize the synergy between medical care and public health programs.
A recent survey conducted by the author in 2017 has shown some encouraging data. All the Haiti-trained family physicians who respond to the questionnaire have stated that the two existing programs have adequately prepared them to confront the challenges of the Haitian medical practice. They estimate that their approach of medical care is well liked by their patients. Over 90% of the respondents have reported that they are satisfied with their career choice and they have a good collaborative relationship with the other specialists.
Importantly, two third of the respondents occupy leadership positions (medical director, programs director, chief of services, technical advisor)
A critical mass of well-trained family doctors will allow the system to have a significant impact on the health of the Haitians communities and effect crucial changes in the managerial culture and practices. An association of Haitian family doctors has been established by Haitian family physicians to promote the specialty, maintain the standards of best practices and advocate for better health care for the communities. It is unclear how many physicians are currently working in Haiti. However, what is important moving forward, is that at least half of the medical specialists produced in the country, would need to be trained as family doctors, in order to assure an adequate coverage of the Haitian population soon.
The pioneering work of the Haiti Project has been the remarkable catalyst of this movement in Haiti. The Haiti Project continues its missionary journey under the auspices of the organization “Friends of Hopital Justinien”, a USA-based entity dedicated to improving the quality of services and medical education in Justinien Hospital, Cap- Haitien. Dr. Michel Dodard and Dr. André Vulcain who helped established the program 20 years ago, are committed to continue to provide managerial and technical direction to the initiative. They regularly travel to Cap- Haitien to lecture and provide guidance. They organize fund-raising activities to collect funds to support the program. They have also taught during the past ten years a family medicine course-the first of this kind- for the senior medical students of the Faculté de Médecine et de Pharmacie de l’Université d’Etat d’Haiti. External funding is critical to implement the academic program and continue to offer much -needed quality clinical services at the family practice center.
Friends and supporters have embraced the program and helped us in keeping the torch lit. Since we have embarked in this journey, our motto was and remains the same, “BETTER HAITIAN HEALTHCARE SYSTEM and HEALTHIER HAITIAN FAMILIES”
André Vulcain, MD
US-trained family physician
Inaugural director and currently Senior Advisor
Family Medicine Residency Program of Hopital Justinien, Cap Haitien,
Haiti Email: avulcain@hotmail.com
March 12th , 2020